The Well-Being Journal

In just a few years, e-cigarettes have advanced from difficult-to-find novelty to readily available commodity widely marketed as a healthier alternative to cigarettes. But with research and regulatory action struggling to keep pace, what do we really know about e-cigarettes?

Food for thought

E-cigarettes, whether manufactured in China or the United States, are not subject to production and content regulation, leading to a multitude of products with inconsistent nicotine delivery and complicating any research on safety and effectiveness.

Usage is increasing dramatically among both youth and adults – about 7% for both in 2012. Alarmingly, a Legacy for Health February 2014 survey found current e-cigarette use at 9% for ages 13-17 and 29% for ages 18-21. Dual use with conventional cigarettes predominates.

Limited population studies and clinical trails have not shown quit efficacy or effectiveness. However, recent data from a survey of almost 6,000 recently quit smokers in England, published on May 21, suggested a promising real-world effectiveness of 1.6 times for e-cigarettes compared to over-the-counter nicotine replacement therapy (NRT) and 1.4 times compared to unaided cessation.

Safety studies have had variable results:

We know ultrafine particles, dependent on the presence of nicotine, are small enough to reach deep into the lungs and subsequently the systemic circulation.

Cytotoxicity is variable among products and can be related to the concentration and number of flavorings.

Secondhand exposure to nicotine as well as other toxins in the vapor has been detected in several studies, albeit usually at lower concentrations than secondhand smoke.

The public health effect

If indeed smoking cessation were as simple as switching from conventional cigarettes to e-cigarettes, undoubtedly there would be significant benefit to the public’s health. But it is not this simple.

Up to a third of youth have only used e-cigarettes. Will this set them on a trajectory toward a lifelong addiction to nicotine and eventually conventional cigarettes?

In addition, most adults are dual users – are they using e-cigarettes to vape in smoke-free environments or to cut down on more costly conventional cigarettes, believing they are at less risk for smoking-related disease? Data do not necessarily support the latter premise. If e-cigarettes delay total abstinence, the health burden may actually increase.

Until clean indoor air policies universally include bans on e-cigarette use (only three states have them to date), there is increasing risk for social acceptance/normalization of smoking/vaping behavior. Fortunately, more states are on board with limiting sales to minors.

What's on the horizon?

If we follow the same course as the past couple years, we can expect continuing exponential growth in e-cigarette consumption. Fortunately, on April 24, 2014, the U.S. Food and Drug Administration (FDA) took the first step toward regulation by proposing a Deeming Regulation to assert jurisdiction over other tobacco products, including e-cigarettes. Unfortunately, the regulation does not include limits on marketing/advertising and flavor additives attractive to youth and will take up to several years for some of the regulations to take effect.

The Patient Protection and Affordable Care Act, according to recently released guidance, requires most health plans to cover FDA-approved smoking cessation products and counseling without any out-of-pocket cost to consumers. E-cigarettes, not proven or approved as cessation tools, will not be covered. This may not be a significant barrier to the escalating use unless more states tax e-cigarettes at a level comparable to conventional cigarettes.

Many questions remain unanswered. How will e-cigarettes be viewed by health plans and employers? Will vapers be considered tobacco users and pay higher healthcare premiums?

The next several years will yield much needed data on the safety and efficacy of e-cigarettes while we observe a natural experiment of "free-range" marketing, easy access and escalating use and wait for guidance and regulation. Until then, the evidence supports a combination of behavioral therapy and FDA-approved cessation aides to assist tobacco users in quitting.

This week, Gallup and Healthways released our analysis of the state of well-being for communities, states and congressional districts in the United States. We've been conducting this research and analysis for six years now, and it always yields interesting tidbits -- for example, Boulder has the nation’s lowest obesity rate at 12.4%, making it the only community in the United States (covered by the report) that meets the Centers for Disease Control and Prevention’s stated goal of 15% obesity rate or lower.

The analysis generates some media attention each year. After all, we care about where we live, and we want to know how our states and communities fare in the rankings. Does the research echo what we believe to be true about our homes and our experiences?

We were excited to see the news covered this year by USA Today,The Huffington Post, the Boston Globe and many other media outlets -- even Diane Sawyer gave us a shout-out on "ABC World News Tonight." That's heady stuff.

But the editorial board at Alabama's relatively small Anniston Star really captured the reason that we collaborate on the Gallup-Healthways Well-Being Index in the first place. Take a look. It's a quick read, but an important one, because Alabama ranked 47th this year, ahead of only three states — Mississippi, Kentucky and West Virginia.

Well-being isn't the same as being happy, nor is it synonymous with good physical health or wealth. Tom Rath, who literally wrote the book on well-being, describes it as "the interaction between physical health, finding your daily work and interactions fulfilling, having strong social relationships and access to the resources you need, feeling financially secure, and being part of a true community."

In short, in areas where well-being is high, people have a greater tendency to be leading their best lives. And that, in turn, impacts business performance, healthcare costs and many other factors that are vital to helping communities thrive and grow.

Understanding where a population -- a state, a community, a company -- stands when it comes to well-being is the first step toward setting successful strategies for improvement. Because well-being can be improved -- it just takes leadership.

As the editorial board of the Anniston Star put it:

Not everyone in Alabama is obese. Not everyone has habits harmful to his or her health. Not everyone has trouble finding decent housing or healthy food. Not everyone has a fatalistic outlook on life. Yet, we all must work together.

Alabama is an example of what happens in the absence of leadership. Too many of its residents are denied an opportunity at the American Dream.

Past performance doesn't lock us into this prison forever. Everyone has a stake in seeing these conditions improve. Our prosperity as a state depends on it.

Sometimes you read something and think, "Yep, that about says it." Check out this article from TheStreet -- not a place where you'll usually catch me hanging out for a good read, but the title, "2014: The Year of Change," drew me in. Here's a little sample to pique your interest:

I don't know what it is, but something about the new year makes us want to reflect on our own imperfections. It makes us think. It forces us face to face with our regrets. It also makes us consider what we can do to make this year better than the last.

"We as humans love fresh beginnings and we get a new chance every January 1st," says Shannon Ryan, a certified financial planner who has worked with individuals and businesses for the last 20 years.

And there's nothing wrong with new year's resolutions, right? In theory, choosing to make one positive change each year could only be a good thing. Think about it. This year could be the year you start exercising. Next year you could focus on nutrition. The year after that could be the year when you finally stop overspending, once and for all.

Then, boom, you've evolved from an exercise-hating spendthrift to a CrossFit enthusiast who saves 90 percent of their income. And you did it all over the span of just a few years, right?

Wrong.

...

In order to move beyond resolutions, you have to make a lifestyle change. And that's exactly why people compare their financial challenges with their relationship with food. The similarities are striking. After all, it's easy to start a new diet on a Monday (don't all diets start on Monday?) and do awesome until about Thursday night when your husband breaks out a giant block of cheese at 10:00 p.m. (story of my life). Then, all of a sudden it's Friday and you're scarfing down nachos at Applebee's while secretly hating yourself. Oh, but you're totally going to restart the whole thing on Monday, right?

The article goes on to share Ryan's tips for getting your financial house in order, which I'm guessing is on the resolutions list for many of us.

Why is it so hard to make lifestyle changes that ultimately improve our overall well-being? Sometimes we just need a little help making the small steps that lead to big change. Healthways is working with the Dave Ramsey organization to make achieving financial well-being a little easier for everyone. It doesn't have to start on January 1 -- you can start any time. Stay tuned -- we'll be sharing more in the coming months.

Gallup editors took a look back at the year in Americans' health and well-being, drawing on data from the Gallup-Healthways Well-Being Index. See their picks for the top 10 most important findings here.

If you've been indulging in a few too many holiday treats, don't forget the exercise, as finding number 10 points out that it's lack of exercise that's most linked to obesity.

The Gallup-Healthways Well-Being Index provides an in-depth, real-time view of Americans' well-being, giving governments, communities, employers and health plans unmatched insight into the health of their populations. The Well-Being Index includes topics such as life evaluation, physical and emotional health, health behaviors, work environment, and basic access.